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Sick Note

Please use this form to send us information about your illness and upload your medical certificate.

Personal Information
Matriculation Number*
First Name*
Last Name*
Nationality
Gender
Age
Address in Bali
Villa/House Name Street Adress City ZIP / Postal Code
Duration of disease
Start*
DD dot MM dot YYYY
End*
DD dot MM dot YYYY
Disease Details
Symptoms
- Feeling unwell
- Fever
- Diarrhea
- Constipation
- Stomach cramps
- Nausea
- Vomiting
- Headache
- Cough
- Runny nose
- A rash on my skin
- A cut / wound
- Ear ache / Ear problems
- Eye problems
- Animal (Dog, Monkey...) bite
- Others
Other Symptoms
Condition
- Could still continue with my usual activities
- Had to rest more than usual
- Had to bed rest (stay in bed)
- Had to stay in a hospital
Hospital Treatment*
- Monitoring
- Therapy
- Surgery
Hospital Stay*
Choosen Action
- I treated myself
- I went to see a doctor
- I went to a hospital
- Others
Other Actions
Examinations
- No extra examination was needed
- X-Ray / Roentgen
- Lab test (blood test, stool test...)
- USG
- CT-Scan
- Others
Other Examinations
Medication
- Antibiotics
- Electrolytes
- Vitamins
- Painkiller
- Anti diarrhea
- Others
Antibiotic Name
Electrolyte Name
Vitamin Name
Painkiller Name
Anti diarrhea Name
Other Medication
Total Costs
- Nothing (free)
- Less than 1 million Rupiah
- 1-2 million Rupiah
- 2-5 million Rupiah
- More than 5 million Rupiah
- More than 10 million Rupiah
Do you have a medical certificate?
- Yes
- No
Medical Certificate
Please keep in mind, we only accept medical certificates from the following institutions:
BIMC, Siloam, Kasih Ibu, Sanglah, Prima Medica, Surya Husada, SOS International, Bali Royal Hospital, Dr. Stefanie Juergens
File
Max. file size: 256 MB.

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Sick Note

Please use this form to send us information about your illness and upload your medical certificate.

Personal Information

Duration of disease

Disease Details

Medical Certificate